Labor and Delivery Care Plan

Labor and Delivery Case Study
Clients Initials______ Age______MSDW
EDC_____________ Gravida______Para_____LC______
Gestation___________ Blood Type and Rh____________ Admission Date and Time_______________
Onset of contractions_____________ Prenatal Classes______________ Culture___________________
List any significant history either prior to pregnancy or during pregnancy (prenatal):
Name which phase of stage I labor the client was in when you initially met the mother:
Describe your assessment of the mother and fetus in terms of: V/S, frequency, duration, and intensity
of contractions, station, rate and pattern of FHTs, dilation and effacement of cervix, amniotic
membranes intact or not, bloody show, presentation and position of fetus, behavior, appearance,
fatigue, breathing techniques, significant others, medications, IVs, edema, Describe the changes in
the assessment that you notice as she goes from phase to phase (latent, active, transition)
Describe nursing actions you performed and ones you observed the nurse provide for the both the client
and her fetus during the first stage of labor. What comfort measures were used to assist the mother?
What medications were given if any? Was any oxygen needed? Provide information to mother about
progress of labor.
Duplicate the monitor strip of the mother and fetus. Describe if it is internal or external explaining the
Evaluate the strip in terms of normal or unusual findings. How were you able to explain the fetal
monitor to the mother?
Describe Stage 2 for the delivery in terms of the type of delivery – spontaneous, vacuum extraction, Csection. If an episiotomy was needed. What type of medication was used for comfort during the
Report on the baby – sex of the baby, Apgar at one minute and at 5 minutes, any resuscitation of the
infant, physical findings. How was infants temperature maintained? How was the infant identified? Was
eye care given and why? Was Vitamin K injection given, how, where and why? What was done to
assist bonding of mother and infant? Describe significant others reaction to the birth.
Describe Stage 3 of the delivery – What were the signs of placental separation? Did the placenta deliver
spontaneous or manual. Was the placenta intact? Were their any lacerations or the repair of an
episiotomy. What type of episiotomy if one was preformed – midline or lateral? Was cord blood
obtained? List any medications administered. What IV’s were given? Give vital signs.
Describe Stage 4 of the delivery – Describe the consistency and position of the fundus, the character and
amount of lochia, condition of perineum, any discomfort, and medications administered. Describe
recovery from anesthesia, LOC, safety measures, fatigue, hunger, thirst, IVs site, urine and voiding
characteristic, comfort and body hygiene, opportunities for bonding, breast feeding if attempted. Need
for warm blankets? Describe how you assessed for any early signs of bleeding.
Chart the hourly time frame of the stages of labor for your mother
9 cm
8 cm
7 cm
6 cm
5 cm
4 cm
3 cm
2 cm
1 cm
0 cm
Describe what you liked about this experience?
What did you find to be the most helpful to your learning about labor and delivery?
How could the experience be improved.